Medical Staff Standards

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Medical Staff Standards New Challenging Prese
ntation by Linda Van Winkle, CPMSM,
CPCS, Manager, Medical Staff Services
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Medical Staff StandardsNew/Challenging

• Determining the competency of practitioners to
  provide high quality, safe patient care is one of
  the most important and difficult decisions an
  organization must make.
• (The Joint Commission)

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Determining competency is accomplished through the processes of Credentialing and Privileging.
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Its not just about paperwork!
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• The Credentialing Privileging processes

involve a series of activities designed
to COLLECT ? VERIFY ? and EVALUATE data relevant
to a practitioners professional performance.
This is the foundation for objective,
evidence-based decisions regarding (a) membership
and (b) privileges.
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• The Credentialing process
• Involves (a) collecting, (b) verifying, (c)
  assessing information regarding 3 critical
  parameters
• Current licensure
• Verification informs the organization that
  applicant is appropriately licensed to practice
  as required by state /or federal law. The
  license verification process is conducted at ALL
  of the following times (a) prior to granting
  initial privileges, (b) prior to re-privileging,
  (c) at time of license expiration.
• Education and relevant training
• Verification informs the organization of
  applicants clinical knowledge and skill set.
  Whenever feasible, verification should be
  obtained from original source of specific
  credential. When not possible, reliable secondary
  sources may be used.
• A reliable secondary source can be another
  hospital that has documented primary source
  verification.
• Experience, ability, current competence to
  perform the requested privileges.
• Verified by peers knowledgeable of applicants
  professional performance. This process may
  include an assessment for proficiency in the 6
  areas of General Competencies.
• Why Verify?
• To minimize possibility of granting privileges)
  based on fraudulent documents.

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• The Credentialing process
• For those of you in Medical Staff Services
  weve come a long way, havent we?
• In 1988 the Joint Commission began to require
  Primary Source Verification (PSV) which changed
  the credentials file from a skinny folder to a
  very fat folder. The reappointment application
  packet was one page, front and back. Now the
  reappointment packet is ½ to 1 thick depending
  on the practitioner.
• HOWEVER the good news in the last few years is
  the impact of the Internet, email, faxing,
  credentialing software, and scanners!!!!
• The PSV process in some aspects takes seconds as
  opposed to the days and even weeks it used to
  take. SCANNING technology saves filing time and
  space. And with TJC now permitting us to share
  PSV with other TJC-accredit4ed hospitals this
  has also been a major time-saver.
• While the credentialing process is becoming more
  and more streamlined, the same cannot be said of
  the privileging process YET!!!

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• The Privileging process
• Typically entails
• Developing and approving a procedures list
• Processing the application
• Evaluating applicant-specific information
• Submitting recommendations to governing body for
  applicant-specific delineated privileges
• Notifying applicant, relevant personnel, and, as
  required by law, external entities re privileging
  decision
• Monitoring the use of privileges and quality of
  care issues
• Add to the above three (3) new TJC Medical
  Standards ?

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• Lets FOCUS
• on these 3 newest concepts related to the
  Credentialing Privileging processes
• 6 General Competencies
• FPPE
• OPPE

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• 1st NEW CONCEPT 6 General Competencies

NEW STANDARD (2007) The integration of the 6
General Competencies into the Credentialing
Privileging processes. The 6 areas Deve
loped by the Accreditation Council for Graduate
Medical Education (ACGME) and the American Board
of Medical Specialties (ABMS) joint
initiative. Why? To allow the organized
medical staff to expand to a more comprehensive
evaluation of a practitioners professional
practice.
Patient Care
Medical/Clinical Knowledge
Practice-based Learning Improvement
Interpersonal Communication Skills
Professionalism
Systems Based Practice
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• 6 General Competencies as defined by TJC -
  Practitioners are expected to

Patient Care provide patient care that is compassionate, appropriate effective for promotion of health, prevention of illness, treatment of disease, care at end of life.
Medical/Clinical Knowledge demonstrate knowledge of established evolving biomedical, clinical social sciences, and the application of their knowledge to patient care and the education of others.
Practice-based Learning Improvement be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.
Interpersonal Communication Skills demonstrate interpersonal communication skills that enable them to establish maintain professional relationships w/patients, families, other members of health care teams.
Professionalism demonstrate behaviors that reflect commitment to continuous professional development, ethical practice, understanding and sensitivity to diversity, responsible attitude toward their patients, their profession, society.
Systems Based Practice demonstrate both an understanding of contexts systems in which health care is provided, ability to apply this knowledge to improve and optimize health care.

• but how to measure?

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• Getting started

• ? Make an inventory of what you are already
  measuring.
• Decide which of the 6 general competency(ies) the
  data satisfies.
• ? Can you pull that data into a profile format
  that can be generated periodically?

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• General Competency 1 -
• Patient Care

For Measures, consider Core Measures (CHF, P, MI data) SCIP Data Results of cases referred to Peer Review Committee Report of diagnoses treated procedures performed Mortality Rates
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• General Competency 2
• Medical/Clinical Knowledge

For measures, consider ? Continuing Medical Education (CME) activities attended ? Board certification ? Appropriateness of antibiobic usage
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• General Competency 3 Practice-based Learning
  Improvement

For Measures, consider Continuing Medical Education (CME) hours related to specialty Post-graduate training, preceptorships Board certification Education regarding pathways, protocols, best practices as a result of cases identified thru peer review cases.
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• General Competency 4 Interpersonal
  Communication Skills

For Measures, consider Patient/Family Satisfaction Survey comments (complaints compliments) Written complaints from peers and associates (e.g., case managers ED staff) Inappropriate comments in medical records about other physicians Monitoring of handwriting legibility. Use of unacceptable abbreviations. Timeliness of HPs and operative notes.
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• General Competency 5 - Professionalism

For Measures, consider Written complaints from peers and associates Inappropriate comments in medical records about other physicians Timeliness of HPs and Operative Reports Medical record suspensions/delinquency MS meeting attendance Responsiveness to ER Call obligations Compliance with MS Bylaws Rules Regs Participation on MS committees
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• General Competency 6 Systems Based Practice

For Measures, consider Avoidable Days Average LOS Utilization of Resources Clinical Pathways
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• Why do we need to measure physician competence?
• Patient Safety
• Quality of Care
• To report to the physician for his/her own use
• (If a hospital provides a physician with reliable
  performance data, performance WILL CONTINUOUSLY
  IMPROVE!)

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• Once you have the 6 General Competency
  measurements defined
• you can incorporate them into the remaining 2 new
  processes
• OPPE and FPPE.
• ?
• Lets look at them now.

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• 2nd NEW CONCEPT
• Ongoing Professional Practice Evaluation (OPPE)
• STANDARD MS.4.40 OPPE information is factored
  into each decision to maintain existing
  privilege(s), revise existing privilege(s), or
  revoke existing privilege(s) prior to or at time
  of renewal.

TRADITIONAL Credentialing Privileging Procedural and cyclical processes practitioners evaluated when privileges are initially granted and every 24 months thereafter i.e., reappointment. ? NEW! OPPE Continuous evaluation of practitioners performance. Requires medical staff to conduct ongoing evaluation of each practitioners performance. Allows ID of professional practice trends that impact quality of care patient safety.
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TJC OPPE CRITERIA may include _ Review of operative other clinical procedure(s) performed and their outcomes Includes operative and other invasive noninvasive procedures that place patient at risk. Focus is on procedures is not meant to include medications that place patient at risk. _ Patterns of blood and pharmaceutical usage _ Requests for tests procedures _ Length of stay patterns _ Morbidity mortality data _ Practitioners use of consultants _ Other relevant criteria as determined by Medical Staff The type of data to be collected is determined by individual departments and approved by the organized medical staff.
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Information used in OPPE may be acquired thru _ Periodic chart review _ Direct observation (proctoring) _ Monitoring of diagnostic and treatment techniques _ Discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel.
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There must be a CLEARLY DEFINED OPPE PROCESS! Relevant information obtained from OPPE is integrated into PI activities. PI activities adhere to policies/procedures intended to preserve confidentiality or legal privilege of information established by applicable law. If there is uncertainty regarding a practitioners professional performance, the Medical Staff should follow course of action defined in the MS Bylaws for further evaluation of a practitioner. NOTE Privileged practitioners have access to the medical staff fair hearing and appeal process should the intervention result in corrective action.
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STANDARD MS.4.45 The organized medical staff evaluates and acts upon reported concerns regarding a privileged practitioners clinical practice and/or competence.
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RATIONALE A well-structured internal reporting process supports OPPE and enhances the quality of care patient safety. Effective OPPE Systematic Measurement Systematic Evaluation Systematic Follow-through

• Based on this equation creating a systematic
  and timely physician competency report will be
  the key to successful OPPE.
• See 26.1 for Sample Physician Competency
  Report. SOURCE The Greeley Company.
• How often will reports be generated?
• Can we modify the CURE report to follow the 6
  General Competencies format and be our OPPE tool?

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What happens when OPPE identifies a problem?
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• This bring us to the 3rd New Concept
• Focused Professional Practice Evaluation (FPPE)
• Standard MS.4.30 effective 1/1/08

FPPE is a process used by the organization in 2 circumstances. Evaluation of privilege-specific competence of a practitioner who does not have documented evidence of competently performing the requested privilege(s) at the organization. AND 2. May be used when a question arises regarding a currently privileged practitioners ability to provide safe, high quality patient care.
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• Focused Professional Practice Evaluation (FPPE)
• Standard MS.4.30 effective 1/1/08

In FPPE the organized Medical Staff does the following Evaluates practitioners without current performance documentation at the organization Evaluates practitioners in response to concerns regarding the provision of safe, high quality patient care Develops criteria for extending the evaluation period Communicates to the appropriate parties the evaluation results and recommendations based on results Implements changes to improve performance
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• Focused Professional Practice Evaluation (FPPE)
• Standard MS.4.30 effective 1/1/08

The FPPE process is defined by the organized Medical Staff. The time period of the evaluation can be extended and/or a different type of evaluation process assigned.
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• Although this standard went into effect 1/1/08,
• approximately 75 of hospitals do not have a
  defined FPPE process in place yet.
• Why?
• What is required?

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• Its a BIG process!!!
• TJC requires use of an FPPE process to confirm
  competency for ALL initially granted privileges.
• AND
• When questions arise in the OPPE process related
  to competency.
• Triggers that indicate the need for performance
  monitoring must be defined.
• TJC is looking for CONSISTENT implementation.

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• Information for FPPE may include
• ? Chart Review
• ? Monitoring clinical practice patterns
• ? Simulation
• ? Proctoring - Prospective, Concurrent, and/or
  Retrospective
• Excellent Resource Proctoring FPPE - The
  Greeley Company. Recently used
• by our new MS President to design a proctoring
  process when questions arose about a
  practitioners competency..
• ? External Peer Review
• ? Discussion with other individuals involved in
  the care of each patient (e.g., consulting
  physicians, assistants at surgery, nursing, or
  administrative personnel).
• COLLABORATION
• among hospital depts (including hospitalists)

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• Elements of Performance
• EP-1 - A period of focused professional practice
  evaluation is implemented for all initially
  requested privileges.
• EP-2 The organized medical staff develops
  criteria to be used for evaluating the
  performance of practitioners when issues
  affecting the provision of safe, high quality
  patient care are identified.

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• Elements of Performance
• EP-3 The performance monitoring process is
  clearly defined and includes each of the
  following elements
• Criteria for conducting performance monitoring
• Method for establishing a monitoring plan
  specific to the requested privilege
• Method for determining the duration of
  performance monitoring
• Circumstances under which monitoring by an
  external source is required.

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• Elements of Performance
• EP-4 FPPE is consistently implemented in
  accordance with the criteria and requirements
  defined by the organized medical staff.
• EP-5 The triggers that indicate the need for
  performance monitoring are clearly defined.
• Triggers can be single incidents or
  evidence of a clinical practice trend.

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• Elements of Performance
• EP-6 The decision to assign a period of
  performance monitoring to further assess current
  competence is based on the evaluation of a
  practitioners current clinical competence,
  practice behavior, and ability to perform the
  requested privilege.
• Other existing privileges in good standing
  should not be affected by this decision.

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• Elements of Performance
• EP-7 Criteria are developed that determine the
  type of monitoring to be conducted.
• EP-8 The measures employed to resolve
  performance issues are clearly defined.
• EP-9 The measures employed to resolve
  performance issues are consistently implemented.

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• The FPPE clock starts ticking
• when an applicant is approved for privileges by
  the Board.
• There must be a mechanism for tracking physicians
  and AHPs undergoing FPPE and ensuring that there
  is an evaluation and action taken at the end of
  the FPPE period.

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• FPPE - Where to Begin?
• Assign an ad hoc task force of medical staff
  members and hospital associates.
• Build on the strengths of existing processes.
  Use your OPPE Physician Competency Reporting
  process, your Peer Review Committee
• Establish accountabilities.
• Assure all participants understand their roles
  accountabilities.
• Document the process in a policy procedure.
• Sample FPPE Policy. Source The Greeley Company.
• Implement.

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• Remember who owns FPPE
• the Organized Medical Staff!
• Who are the Key Individuals/Groups?
• for Design of FPPE
• Medical Staff Organization leaders
• Dept Chairs/Section Chiefs
• Credentials Committee
• PI Committee/Peer Review Committee
• MEC
• for Support of FPPE
• Medical Staff Services Department
• Quality Management Department

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• FPPE What are Typical Roles of Key
  Individuals/Groups?
• Medical Staff Services Department
• Communicating requirements to involved
  practitioners and staff
• Tracking
• Reporting (status reports)
• Notifying (practitioners, dept chairs, etc.)
• Summarizing and presenting results
• Documentation of the review process, ensuring
  follow-through.
• Quality Management Department
• Supporting the peer review-like processes
• Screening cases
• Facility of review processes (participation in
  committees and with individuals)
• Collecting any required aggregate data
• Forwarding results of review to MSSD

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• FPPE What are Typical Roles of Key
  Individuals/Groups?
• Each Clinical Specialty
• Examines current methods systems for confirming
  competency for new applicants/new privileges.
• Evaluates current privilege forms to determine
  scope of services for which competency
• needs to be confirmed.
• Identifies what new methods for confirmation of
  competency need to be developed.
• Develops specialty-specific written
  plan/guidelines.
• Submits guidelines to Credentials Committee.
• Department Chairs
• Tailor guidelines to new applicants
• (depending on privileges requested, knowledge of
  applicants current competency, etc.).
• Make written recommendation related to FPPE
• (along with recommendation related to granting of
  privileges)

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• FPPE more typical Roles of Key
  Individuals/Groups
• Credentials Committee
• Develops overall policy/procedure for FPPE
• Evaluates recommendations/plans made by
  department chairs.
• Medical Executive Committee
• Final recommending authority for FPPE.
• Board of Directors
• Final approval/denial authority for FPPE.

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• FPPE Process - What will it take?
• ?Education of Elected Medical Staff Leaders and
  hospital associates who support the FPPE process.
• ? Selection of MS leaders willing to take on the
  challenge spend the time it will take.

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• Developing
• maintaining
• credible processes
• to determine competency
• requires
• diligent
• data collection
• data evaluation.

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• ? And Collaboration!!!!
• COLLABORATION among hospital depts (including
  hospitalists) and the Medical Staff is KEY.
• Dont work in a vacuum.

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• Collaboration!!!! (contd)
• Understand each department/areas specific
  accountabilities.
• Identify required outputs/inputs.
• Flow diagram.
• Imbed utilization of IT.

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Get the right information to the right people at
the right time! Peer Review
Committee Department Chairs Credentials Committee
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Ensure Analysis and Evaluation
And Follow-Through, to Competent
Practitioners providing Quality, Safe Patient
Care!!!
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• Some last-minute FPPE Lessons Learned
• Develop overall policy before
• developing individual FPPE criteria.
• Make guidelines reasonable attainable.
• Do not overuse labor-intensive FPPE methods such
  as concurrent proctoring.
• Build in ability to shorten or lengthen
• FPPE process as situation requires.

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• Lets work together to get the processes in
  place!